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Dilday J, Chien CY, Lewis MR, Benjamin ER, Demetriades D. Proximal protective diverting ostomy following colon anastomosis for penetrating trauma may not be protective: A matched cohort study. Am J Surg 2024; 228:237-241. [PMID: 37863797 DOI: 10.1016/j.amjsurg.2023.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/28/2023] [Accepted: 10/05/2023] [Indexed: 10/22/2023]
Abstract
INTRODUCTION Despite the shift toward liberal primary anastomosis in penetrating colon injuries, some surgeons recommend a protective diverting ostomy (DO) proximal to the anastomosis. This study evaluates the effect of DO on outcomes in patients undergoing colon resection and anastomosis following penetrating trauma. METHODS The TQIP database (2013-2018) was queried for penetrating colon injuries undergoing colectomy and anastomosis. Patients receiving DO were propensity matched to patients without diverting ostomy (woDO) (1:3). Outcomes were compared between groups. RESULTS After matching, 89 DO patients were analyzed. The DO group had more surgical site infections (32 % vs. 21 %; p < 0.05) and longer hospital stay (20 [13-27] vs. 15 [9-25]; p < 0.05) compared to the woDO group. Mortality and unplanned operations were similar between groups. CONCLUSIONS Diverting ostomy after colon resection and anastomosis is associated with increased infectious complications without decreasing unplanned operations or mortality. Its routine role in penetrating colon trauma needs reassessment.
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Affiliation(s)
- Joshua Dilday
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, USA.
| | - Chih Ying Chien
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, USA; Department of General Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan.
| | - Meghan R Lewis
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, USA.
| | - Elizabeth R Benjamin
- Department of Trauma and Surgical Critical Care, Grady Memorial Hospital, Atlanta, GA, USA.
| | - Demetrios Demetriades
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, USA.
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Grossman H, Dhanasekara CS, Shrestha K, Marschke B, Morris E, Richmond R, Ko A, Tennakoon L, Campion EM, Wood FC, Brandt M, Ng G, Regner JL, Keith SL, McNutt MK, Kregel H, Gandhi RR, Schroeppel TJ, Margulies DR, Hashim YM, Herrold J, Goetz M, Simpson L, Doan XL, Dissanaike S. Rates and risk factors for anastomotic leak following blunt trauma-associated bucket handle intestinal injuries: a multicenter study. Trauma Surg Acute Care Open 2023; 8:e001178. [PMID: 38020867 PMCID: PMC10668238 DOI: 10.1136/tsaco-2023-001178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
Objectives The risk factors for anastomotic leak (AL) after resection and primary anastomosis for traumatic bucket handle injury (BHI) have not been previously defined. This multicenter study was conducted to address this knowledge gap. Methods This is a multicenter retrospective study on small intestine and colonic BHIs from blunt trauma between 2010 and 2021. Baseline patient characteristics, risk factors, presence of shock and transfusion, operative details, and clinical outcomes were compared using R. Results Data on 395 subjects were submitted by 12 trauma centers, of whom 33 (8.1%) patients developed AL. Baseline details were similar, except for a higher proportion of patients in the AL group who had medical comorbidities such as diabetes, hypertension, and obesity (60.6% vs. 37.3%, p=0.015). AL had higher rates of surgical site infections (13.4% vs. 5.3%, p=0.004) and organ space infections (65.2% vs. 11.7%, p<0.001), along with higher readmission and reoperation rates (48.4% vs. 9.1%, p<0.001, and 39.4% vs. 11.6%, p<0.001, respectively). There was no difference in intensive care unit length of stay or mortality (p>0.05). More patients with AL were discharged with an ostomy (69.7% vs. 7.3%, p<0.001), and the mean duration until ostomy reversal was 5.85±3 months (range 2-12.4 months). The risk of AL significantly increased when the initial operation was a damage control procedure, after adjusting for age, sex, injury severity, presence of one or more comorbidities, shock, transfusion of >6 units of packed red blood cells, and site of injury (adjusted RR=2.32 (1.13, 5.17)), none of which were independent risk factors in themselves. Conclusion Damage control surgery performed as the initial operation appears to double the risk of AL after intestinal BHI, even after controlling for other markers of injury severity. Level of evidence III.
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Affiliation(s)
- Holly Grossman
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | | | - Kripa Shrestha
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Brianna Marschke
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Erin Morris
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Robyn Richmond
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Ara Ko
- Department of Surgery, Stanford Medicine, Stanford, California, USA
| | | | - Eric M Campion
- Department of Surgery, Denver Health Medical Center, Denver, Colorado, USA
| | - Frank C Wood
- Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Maggie Brandt
- Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Grace Ng
- Department of Surgery, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Justin L Regner
- Department of Surgery, Baylor Scott & White Medical Center Temple, Temple, Texas, USA
| | - Stacey L Keith
- Department of Surgery, Baylor Scott & White Medical Center Temple, Temple, Texas, USA
| | - Michelle K McNutt
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Heather Kregel
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Rajesh R Gandhi
- Department of Surgery, JPS Health Network, Fort Worth, Texas, USA
| | | | - Daniel R Margulies
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Yassar M Hashim
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Joseph Herrold
- Department of Surgery, University of Maryland, Baltimore, Maryland, USA
| | - Mallory Goetz
- Department of Surgery, University of Maryland, Baltimore, Maryland, USA
| | - LeRone Simpson
- Department of Surgery, McAllen Medical Center, McAllen, Texas, USA
| | - Xuan-Lan Doan
- Department of Surgery, McAllen Medical Center, McAllen, Texas, USA
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
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Oosthuizen GV, Klopper J, Buitendag J, Variawa S, Čačala SR, Kong VY, Couch D, Clarke DL. Penetrating colon trauma-the effect of concomitant small bowel injury on outcome. Injury 2022; 53:1615-1619. [PMID: 35034775 DOI: 10.1016/j.injury.2021.12.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 12/12/2021] [Accepted: 12/29/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION There is limited evidence to suggest that patients with penetrating colon injury have higher complication rates when there is concomitant small bowel (SB) injury. AIM We performed a retrospective study looking at outcomes of penetrating colonic trauma in patients with- and without concomitant SB injury. METHODS We interrogated our electronic registry over an eight-year period (2012-2020) for all patients over 18 years who had sustained penetrating colon injury and who had survived beyond 72 h. Demographic data, admission physiology, and Injury Severity Score (ISS) were recorded. Two groups of patients were observed: those with colonic injury (no SB injury) and those with combined colon and SB injury. Outcomes observed included leak rates, length of Intensive Care Unit (ICU) stay, length of hospital stay (LOS), morbidity and mortality. RESULTS A total of 450 patients were eligible for analysis, of which 257 had colon injury without SB injury and 193 had a combination of colon and SB injury. There was no difference in mechanism of injury between groups. Admission physiology was similar between groups but arterial blood gas values were worse in the combined group. Rates of damage control surgery and ICU admission were higher in the combined group. Primary repair was done in equal proportions between groups but anastomosis was more frequently performed in the combined group. There was no difference in complication rates, including gastro-intestinal complications and suture line leaks. Length of ICU stay, LOS, and mortality were similar between groups. Univariable analysis demonstrated that the presence of concomitant small bowel injury was not an independent risk factor for colonic suture line failure or death. CONCLUSION There is no evidence from this data that the presence of a combined penetrating colon and SB injury should change management priorities. Each injury should be treated on its own merit, in the context of the patient's physiology.
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Affiliation(s)
- G V Oosthuizen
- Department of Surgery, Ngwelezana Hospital, Empangeni, South Africa; Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - J Klopper
- Division of Epidemiology and Biostatistics, University of Stellenbosch, Cape Town, South Africa
| | - Johan Buitendag
- Department of Surgery, University of Stellenbosch, Milnerton, Cape Town, South Africa.
| | - S Variawa
- Department of Surgery, Khayelitsha District Hospital, Cape Town, South Africa
| | - S R Čačala
- Department of Surgery, Ngwelezana Hospital, Empangeni, South Africa; Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - V Y Kong
- Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - D Couch
- Department of Surgery, Queens Medical Centre, Nottingham, United Kingdom
| | - D L Clarke
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa; Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa; Department of Surgery, Grey's Hospital, Pietermaritzburg, South Africa
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McKnight GHO, Yalamanchili S, Sanchez-Thompson N, Guidozzi N, Dunhill-Turner N, Holborow A, Batrick N, Hettiaratchy S, Khan M, Kashef E, Aylwin C, Frith D. Penetrating gluteal injuries in North West London: a retrospective cohort study and initial management guideline. Trauma Surg Acute Care Open 2021; 6:e000727. [PMID: 34395917 PMCID: PMC8311336 DOI: 10.1136/tsaco-2021-000727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/22/2021] [Indexed: 11/10/2022] Open
Abstract
Background Penetrating gluteal injuries (PGIs) are an increasingly common presentation to major trauma centers (MTCs) in the UK and especially in London. PGIs can be associated with mortality and significant morbidity. There is a paucity of consistent guidance on how best to investigate and manage these patients. Methods A retrospective cohort study was performed by interrogating prospectively collected patient records for PGI presenting to a level 1 MTC in London between 2017 and 2019. Results There were 125 presentations with PGI, accounting for 6.86% of all penetrating injuries. Of these, 95.2% (119) were male, with a median age of 21 (IQR 18–29), and 20.80% (26) were under 18. Compared with the 3 years prior to this study, the number of PGI increased by 87%. The absolute risk (AR) of injury to a significant structure was 27.20%; the most frequently injured structure was a blood vessel (17.60%), followed by the rectum (4.80%) and the urethra (1.60%). The AR by anatomic quadrant of injury was highest in the lower inner quadrant (56%) and lowest in the upper outer quadrant (14%). CT scanning had an overall sensitivity of 50% and specificity of 92.38% in identifying rectal injury. Discussion The anatomic quadrant of injury can be helpful in stratifying risk of rectal and urethral injuries when assessing a patient in the emergency department. Given the low sensitivity in identifying rectal injury on initial CT, this data supports assesing any patients considered at high risk of rectal injury with an examination under general anesthetic with or without rigid sigmoidoscopy. The pathway has created a clear tool that optimizes investigation and treatment, minimizing the likelihood of missed injury or unnecessary use of resources. It therefore represents a potential pathway other centers receiving a similar trauma burden could consider adopting. Level of evidence 2b.
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Affiliation(s)
- Gerard Hywel Owen McKnight
- Institute of Naval Medicine, Royal Navy, Gosport, UK.,Major Trauma, Imperial College Healthcare NHS Trust, London, UK
| | - Seema Yalamanchili
- Major Trauma, Imperial College Healthcare NHS Trust, London, UK.,Division of Surgery and Cancer, Imperial College London Faculty of Medicine, London, UK
| | | | - Nadia Guidozzi
- Major Trauma, Imperial College Healthcare NHS Trust, London, UK
| | | | - Alex Holborow
- Department of Radiology, Swansea Bay University Health Board, Swansea, UK
| | - Nicola Batrick
- Major Trauma, Imperial College Healthcare NHS Trust, London, UK
| | | | - Mansoor Khan
- Major Trauma, Imperial College Healthcare NHS Trust, London, UK
| | - Elika Kashef
- Major Trauma, Imperial College Healthcare NHS Trust, London, UK
| | - Chris Aylwin
- Major Trauma, Imperial College Healthcare NHS Trust, London, UK
| | - Dan Frith
- Major Trauma, Imperial College Healthcare NHS Trust, London, UK
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